Pelvic support abnormalities and urinary incontinence

Question 1

What are the key pelvic support abnormalities?

Answer 1

cystocele
rectocele
enterocele
vault prolapse

Question 2

What is a cystocele?

Answer 2

A cystocele occurs when the wall between a woman’s bladder and her vagina weakens and allows the bladder to droop into the vagina.

Question 3

What is a rectocele?

Answer 3

A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina.

Question 4

What is a enterocele?

Answer 4

An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal

Question 5

What is a vault prolapse?

Answer 5

Vaginal prolapse is a condition in which the vagina, or structures near it begin to prolapse, or fall out of its normal position

Question 6

What is the principal etiology of a cytocele and rectocele?

Answer 6

vaginal delivery

Question 7

What is the principal etiology of a enterocele and vault prolapse?

Answer 7

prior hysterectomy

Question 8

What are the clinical manifestations of a cystocele?

Answer 8

sense of prolapse, vaginal pressure, urinary incontinence

Question 9

What are the clinical manifestations of a rectocele?

Answer 9

sense of prolapse, rectal pressure, entrapped stool

Question 10

What are the clinical manifestations of a enterocele?

Answer 10

sense of prolapse, dyspareunia

Question 11

What are the clinical manifestations of a vaginal prolapse?

Answer 11

sense of prolapse, dyspareunia, perineal pain, vaginal infection

Question 12

How do you manage a cystocele?

Answer 12

pessary surgery- may cause incontinence

Question 13

How do you manage a rectocele?

Answer 13

stool softeners, laxatives; surgery- may cause dyspareunia

Question 14

How do you manage a enterocele?

Answer 14

pessary surgery

Question 15

How do you manage a vault prolapse?

Answer 15

pessary surgery- resuspend vault or close the vagina

Question 16

What goes into the differential diagnosis of urinary incontinence?

Answer 16

overflow incontinence (neurogenic bladder)
urge incontinence
stress incontinence

Question 17

What are possible etiologies of overflow incontinence?

Answer 17

neurologic disorder (MS, MD)
spinal cord injury
diabetes

Question 18

What are possible etiologies of urge incontinence?

Answer 18

anxiety
infection
polyp
tumor

Question 19

what are possible etiologies of stress incontinence?

Answer 19

childbirth (especially vaginal delivery)
prior pelvic surgery (repair of cystocele)
estrogen deficiency

Question 20

What are common characteristics of overflow?

Answer 20

no sense of urgency, loss occurs when bladder is overfilled

Question 21

What are common characteristics of urgency?

Answer 21

immediate sense of needing to void

Question 22

What are common characteristics of stress?

Answer 22

precipitated by coughing, sneezing, straining or exercising

Question 23

How do you evaluate urinary incontinence?

Answer 23

physical exam- identify neuromuscular disease
urine culture- exclude infection
cystoscopy- evaluate for polyps, tumor, inflammation
urodynamic testing- confirm stress incontinence

Question 24

What is the proper management of overflow incontinence?

Answer 24

treatment of underlying condition
treatment and prevention of infection
catherterization as indicated

Question 25

What is the proper management of urge incontinence?

Answer 25

reduce weight
stop smoking
decrease, if not eliminate, caffeine intake
re-train bladder
medication- muscarinic receptor blockers (oxybutynin-ER 5-15 mg daily)

Question 26

What is the proper management of stress incontinence?

Answer 26

lose weight
avoid caffeine
re-train bladder
empty bladder immediately before exercising

Surgical:
trans-abdominal procedure, rarely used today
transvaginal procedure (TVT, TOT)
Collagen injection

Question 27

Which incontinence usually requires surgery?

Answer 27

stress

Question 28

Which incontinence responds the best to medical therapy?

Answer 28

urge